Subjective - class 3 Flashcards
Onset
When did the complaint occur
Timing
Has the complaint been constant, intermittent, or waxing/waning (how often does it occur)
Location
Where is the discomfort
Quality
Does it feel sharp, dull, aching, cramping, etc…
Severity
How bad is it? Mild, moderate, or severe on a 1-10 scale
Modifying factors
What makes it better or worse
Associated Sx
Do any other symptoms accompany the Chief Complaint
Context
Is there anything else that is important
HPI/history of present illness
The story of symptoms and events that led to the clinic visit. Summaries of the reason for the visit.
ROS/Review of systems
Head to toe overview of the patients body systems phrased in the form or positives and negatives including symptoms not relevant to the chief complaint but NOT the context
What is the subjective information?
Information coming directly from the person giving the history
Chief complaint
HPI
ROS
What are the 3 primary methods of structuring an outpatient HPI
Simple complaint formula
Multiple complaint formula
Chronologic formula
Single complaint formula
Best formula for patients with only 1-2 complaints that have not been previously evaluated.
This is the most common
Multiple complaint formula
Formula used for patients who have multiple complaints, as routine follow up for chronic illnesses, and for different treatment plans for different complaints
Chronologic formula
Best structure for complex stories such as patients with multiple comorbidities, patients who have had a significant work up or evaluation, and established patients there for follow up of a chronic illness
